New York State
Workers' Compensation Board
OFFICE OF CONTINUOUS IMPROVEMENT
20 Park Street Albany, New York 12207
Workers' Compensation Board
OFFICE OF CONTINUOUS IMPROVEMENT
20 Park Street Albany, New York 12207
Andrew M. Cuomo
Governor
Subject No. 046-1.16
Governor
Subject No. 046-1.16
New And Revised Workers' Compensation Board Forms
1-1-11 through 1-31-12
Date: March 19, 2012
The table below shows Workers' Compensation Board forms that have been recently issued or revised. Most of these forms are available on the Board's website (www.wcb.ny.gov) under the heading Forms. For information on any Board form, contact the Board's Forms Department at FormsDepartment@wcb.ny.gov.
While most of these forms have been updated simply to reflect the new Buffalo mailing address, the following forms contain these substantive changes:
- C-4.3 was modified to accommodate the 2012 Guidelines for Determining Permanent Impairment and Loss of Wage Earning Capacity.
- PH-16.2 was modified to accommodate implementation of the 2010 New York State Construction Industry Fair Play Act (Labor Law § 861).
- RFA-1LC and RFA-2 were reorganized to allow parties to identify the issue involved and to instruct parties as to what evidence is required for further development of the issue.
- SI-10.1 was updated to reflect cumulative compensation payments through 9/30/11.
- VDF-1 was created to accommodate the 2012 Guidelines for Determining Permanent Impairment and Loss of Wage Earning Capacity.
- W-32R was updated to reflect changes within the Board's WAMO office.
Forms Department
| FORM NO. | TITLE | DATE |
|---|---|---|
| ADR-1 | Alternative Dispute Resolution Program Report of Injury | Jan-11 |
| ADR-1.1 | Modification of Previous Report | Jan-11 |
| ADR-2 | Alternative Dispute Resolution Program Final Disposition on Settlement of Claim | Jan-11 |
| AFF-1 | Affidavit for Death Benefits | Jan-11 |
| C-105 | Notice of Compliance - Workers' Compensation Law | Jan-11 |
| C-11 | Employer's Report of Injured Employee's Change in Work Status Resulting from Injury | Jan-11 |
| C-121 | Claim for Compensation and Notice of Commencement of Third Party Action | Jan-11 |
| C-18.6 | Information to Claimant Under Section 15, Subd. 3 | Jan-11 |
| C-2.0 | Employer's Report of Work-Related Injury/Illness | Jan-11 |
| C-21 | Application for an Advance on Periodic Payments of Compensation | Jan-11 |
| C-22 | Application for Approval of Non-Schedule Adjustment | Jan-11 |
| C-240 | Employer's Statement of Wage Earnings | Jan-11 |
| C-25 | Application for Reopening of Claim More Than Seven Years After Accident | Jan-11 |
| C-251.3 | Notice of Right to Reimbursement of Compensation Payments Under Section 14(6) & Section 15(8) | Jan-11 |
| C-27 | Medical Proof of Change in Condition in Support of Application for Reopening of Claim | Jan-11 |
| C-3.0 | Employee's Claim for Compensation | Jan-11 |
| C-32.1 | Settlement Agreement - Section 32 - Claimant Release | Jan-11 |
| C-3S | Spanish Employee's Claim for Compensation | Jan-11 |
| C-4 AMR | Ancillary Medical Report | Jan-11 |
| C-4 AUTH | Attending Doctor's Request for Authorization and Carrier's Response | Jan-11 |
| C-4.0 | Attending Doctor's Report and Carrier/Employer Billing Form | Jan-11 |
| C-4.2 | Doctor's Progress Report | Jan-11 |
| C-4.3 | Doctor's Report of MMI/Permanent Impairment | Jan-12 |
| C-430S | Statement of Rights | Jan-11 |
| C-5 | Attending Ophthalmologist's Report | Jan-11 |
| C-62 | Claim for Compensation in a Death Case | Jan-11 |
| C-64 | Proof of Death | Jan-11 |
| C-65 | Proof of Burial and Funeral Expenses - by Undertaker | Jan-11 |
| C-669 | Notice to Chair of Carrier's Action on Claim for Benefits | Jan-11 |
| C-7.0 | Notice That Right to Compensation is Controverted | Jan-11 |
| C-8.1 | Notice of Treatment Issue(s)/Disputed Bill Issue(s) | Jan-11 |
| C-8.4 | Notice to Health Care Provider and Injured Worker of a Carrier's Refusal to Pay All (Or A Portion Of) a Medical Bill Due to Valuation Objection(s) | Jan-11 |
| C-8/8.6 | Notice to Chair that Payment of Compensation Has Been Stopped or Modified | Jan-11 |
| DB-120 | Notice of Compliance - Disability Benefits Law | Jan-11 |
| DB-271S | Statement of Rights - Disability Benefits Law | Jan-11 |
| DB-470 | Preliminary Claim for Reimbursement of Benefits Paid Under the NYS DBL | Jan-11 |
| DC-120 | Discharge or Discrimination Complaint | Jan-11 |
| FCE-4 | Practitioner's Report of Functional Capacity Evaluation | Jan-11 |
| IME-3 | Practitioner's Report of Request for Information/Response to Request for Information Regarding Independent Medical Examination | Jan-11 |
| IME-4 | Practitioner's Report of Independent Medical Examination | Jan-11 |
| IME-5 | Claimant's Notice of Independent Medical Examination under Section 137 WCL | Jan-11 |
| MD-1 | Attending Doctor's Request for Medical Authorization Determination | Jan-11 |
| MD-3 | Carrier/Self-Insurer's Objection to Attending Doctor's Request for Medical Authorization Determination | Jan-11 |
| MG-1 | Attending Doctor's Request for Optional Prior Approval and Carrier's/Employer's Response | Jan-11 |
| MG-2 | Attending Doctor's Request for Approval of Variance and Carrier's Response | Jan-11 |
| MR-4 | Impartial Specialist's Report of Medical Records Review | Jan-11 |
| OC-110A | Claimant's Authorization to Disclose Workers' Compensation Records | Jan-11 |
| OC-110AS | Claimant's Authorization to Disclose Workers' Compensation Records - Spanish Version | Jan-11 |
| OC-400 | Notice of Retainer and Appearance/Substitution and Appearance | Jan-11 |
| OC-400.1 | Application for a Fee by Claimant's Attorney or Representative | Jan-11 |
| OC-923 | Letter to New Employer Re W.C. and D.B. Coverage | Jan-11 |
| OT/PT-4 | Occupational/Physical Therapist's Report | Jan-11 |
| PH-16.2 | Pre-Hearing Conference Statement | Feb-11 |
| PS-4 | Psychologist's Report | Jan-11 |
| RB-89 | Cover Sheet - Application for Board Review | Jan-11 |
| RB-89.1 | Cover Sheet - Rebuttal of Application for Board Review | Jan-11 |
| RB-89.2 | Cover Sheet - Application for Full Board Review | Jan-11 |
| RB-89.3 | Cover Sheet - Rebuttal of Application for Full Board Review | Jan-11 |
| RFA-1LC | Request for Further Action by Legal Counsel | May-11 |
| RFA-1W | Request for Assistance by Injured Worker | Jan-11 |
| RFA-2 | Carrier's/Employer's Request for Further Action | May-11 |
| SI-10.1 | Report of Cumulative Compensation Payments | Sep-11 |
| VAW-105 | Notice of Compliance - Volunteer Ambulance Workers' Law | Jan-11 |
| VAW-2 | Political Subdivision's Report of Injury to Volunteer Ambulance Worker | Jan-11 |
| VAW-3 | Volunteer Ambulance Worker's Claim for Benefits | Jan-11 |
| VAW-62 | Claim for Volunteer Ambulance Workers' Benefits in a Death Case | Jan-11 |
| VDF-1 | Loss of Wage Earning Capacity, Vocational Data Form | Jan-12 |
| VF/VAW-11C | Volunteer's Notification of Executive Officer of Fire/Ambulance Company of Significant Risk of Transmission of HIV Under Sec. 11-C(1) VFBL/VAWBL | Jan-11 |
| VF/VAW-305 | Letter re: Injured in the Line of Duty | Jan-11 |
| VF-105 | Notice of Compliance - Volunteer Firefighters Benefit Law | Jan-11 |
| VF-2 | Political Subdivision's Report of Injury to Volunteer Firefighter | Jan-11 |
| VF-3 | Volunteer Firefighter's Claim for Benefits | Jan-11 |
| VF-62 | Volunteer Firefighter's Claim for Compensation in a Death Case | Jan-11 |
| W-32R | WAMO Settlement Agreement - Section 32 WCL | Mar-11 |
| WTC-12 | Registration of Participation in World Trade Center Rescue, Recovery and/or Clean-Up Operations | Jan-11 |
| 